1851998710 NPI number — MAGNO C. SANTOS MSN, FNP-C PLLC

Table of content: (NPI 1851998710)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851998710 NPI number — MAGNO C. SANTOS MSN, FNP-C PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MAGNO C. SANTOS MSN, FNP-C PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1851998710
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/16/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 271
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RUPERT
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83350-0271
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-936-8206
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2300 N YELLOWSTONE HWY # 104
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
IDAHO FALLS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83401-1662
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-538-1963
Provider Business Practice Location Address Fax Number:
208-615-8005
Provider Enumeration Date:
10/05/2020

Additional Information

Authorized Official

Authorized Official Last Name:
SANTOS
Authorized Official First Name:
MAGNO
Authorized Official Middle Name:
C
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
208-538-1963

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: IDTPID015961 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".




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